Breast biopsy with needle localization: influence of age and mammographic feature on the rate of malignancy in 350 nonpalpable breast lesions

The purpose of this study was to determine the influence of mammographic feature and patient age on the rate of malignancy in nonpalpable breast lesions. During a 3-year period, 305 patients underwent biopsy after needle localization of 350 nonpalpable breast lesions. A total of 66 malignant breast tumors were found (biopsy yield rate, 19%): 23 carcinoma in situ, 43 infiltrating cancer. The biopsy yield rate in women younger than 50 years was 8% (12 of 153) and in women 50 years or older 27% (54 of 197; p less than 0.001). The biopsy yield rate varied with the mammographic feature in both groups of patients and was highest for spicular masses (61%), followed by strongly suspicious calcifications (29%). No cancers were found among well-defined masses or asymmetric densities. Other factors that were associated with high biopsy yield rate were personal or family history of breast cancer and diagnostic, rather than screening, mammography. The results suggest that the rate of malignancy in nonpalpable breast lesions is influenced by several factors, including age of patient and mammographic feature of the lesion. By taking all these factors into account, biopsies can possibly be performed more selectively thereby increasing the cost effectiveness of biopsy for occult breast cancer.     

Relation between clinical and mammographic diagnosis of breast problems and the cancer/biopsy rate

Objective

To determine the sensitivity of mammographic and clinical assessment of breast problems, independent of one another, on the ratio of cancers found to biopsies performed (cancer/biopsy rate).

Design

A review of diagnoses from prospectively recorded and independently assessed clinical and mammographic examinations.

Setting

The breast clinic in a university-affiliated hospital.

Patients

Patients were considered in two age groups — under 50 years and 50 years and over; 1251 patients underwent breast biopsy between September 1976 and November 1994 after clinical assessment and mammography.

Main Outcome Measure

The cancer diagnosis rate found on biopsy as a result of clinical and mammographic findings.

Results

In both age groups, mammography was significantly (p < 0.001) more sensitive than clinical assessment in cancer diagnosis but gave a significantly (p < 0.0001) higher rate of false-positive results. The cancer diagnosis rate was highest when lesions were assessed both clinically and mammographically as malignant but was of diagnostic benefit only to women in the under-50-year age group. The cancer rate was 12% when both assessments indicated a benign process and only 2% in women under age 50 years with clinically benign conditions who did not have mammography. Twenty-one percent of the biopsies were obtained in women with clinically normal breasts because of a mammographic abnormality and 17% of all the cancers found were clinically occult.

Conclusions

The sensitivity of clinical assessment, particularly in premenopausal women is low and the false-positive mammography rate is high, but the cancer/biopsy rate is sufficiently high to warrant breast biopsy if either diagnostic modality suggests a cancer. When neither modality suggests cancer, the cancer/biopsy rate is 12% in both age groups.     

The diagnosis of breast cancer in women younger than 40

This study examined how the diagnosis of breast cancer is different in young women. Records were retrieved for 239 women diagnosed with breast cancer before age 40 and compared with 2101 women aged 40 and over with breast cancer. On mammography, lesions in the younger women were more likely to be undetected or interpreted as benign, especially in women with dense breasts. However, there were 10 young women where impalpable cancers with microcalcification under 10 mm would not have been diagnosed without mammography. An abnormality was detected on ultrasound in 92.2% of cancers in young women, but was more likely to be considered benign than in older women. If ultrasound alone had been used in the young women, at least 18 cancers would have been missed. Ultrasound was useful for predicting the ultimate tumour size at pathology, and for detecting multifocality. There were 14 cases where the ultrasound appearance was indistinguishable from fibroadenoma. The importance of fine needle aspiration cytology in the diagnosis of focal lesions in young women (over 20 years) was confirmed. For symptomatic women, the proportion of breast malignancies under 10 mm was similar in the two groups. However, the younger group had significantly more poorly differentiated tumours.     

Productivity of needle localization to facilitate excision of nonpalpable, mammographically suspicious lesions

The use of needle localization to aid excisional biopsy of nonpalpable breast lesions is now common, and the literature suggests that 13% to 33% of such lesions are malignant. During the 4 years from 1984 to 1988, all women who underwent fine-needle localization in preparation for biopsy were studied to identify factors that might facilitate the selection of those more likely to harbour a cancer, thus sparing patients with benign disease operative intervention. In all, 124 biopsies were performed on nonpalpable lesions that were suspicious on mammography; 51 lesions were malignant and 73 benign. The average age of the patients was 56 years (55 years for those with benign lesions and 61 for those with malignant lesions). The family history, history of breast disease, symptoms and calcification seen on mammography were not significantly different between the two groups. Only 25% of the malignant lesions were noninvasive. In 10% of the patients who had invasive lesions there was lymph-node involvement. The rate of malignancy in this patient population (41%) was slightly better than that reported in the literature, and a larger proportion of patients had noninvasive disease. The authors conclude that none of the above-mentioned risk factors could be used in the preoperative selection of patients for open biopsy.     

Trends in breast cancer at a county hospital

Breast cancer mortality has changed dramatically with improvements in screening techniques. Mammography is essential for early detection; however, its contribution to the survival benefit in young women is questionable. We report our experience in breast biopsies at a county teaching hospital with a traditionally younger patient population. Institutional review board approval was obtained prior to data collection. A total of 550 breast biopsies were conducted between 1995 and 2000. Data regarding age, method of breast biopsy, and pathology was reviewed. One hundred twenty of 550 patients (21.8%) had breast carcinoma detected on breast biopsies with the predominant histologic subtype being invasive ductal carcinoma. The mean age of patients with carcinoma was 52.8 years, whereas that of patients with benign breast disease was 43.6 years (P < 0.05). Forty-three per cent of all breast cancers occurred in women under the age of 50 years. During the study period, there was neither an increase in the number of breast biopsies performed per year nor a decrease in the average age of women with breast cancer. However, observing a significant percentage of breast cancer patients under 50 years old, our data suggest the importance of strict adherence to current screening recommendations including self-breast examination and yearly mammography.     

The complementary role of fine needle aspiration cytology and Tru-cut needle biopsy in the management of breast masses

Fine needle aspiration cytology (FNA) and Tru-cut needle biopsy (TNB) have been used for the pre-operative diagnosis of cancer in breast masses as alternatives to open breast biopsy. The accuracy of clinical examination, fine needle aspiration biopsy and Tru-cut needle biopsy was assessed in 230 patients with palpable breast masses and the value of using both biopsy methods in the management was prospectively evaluated. Clinical diagnosis had a sensitivity of 89.2% and specificity of 78.4% (32.7% false positive, 6.5% false negative). Aspiration cytology was diagnostic in 78.4% of cancers and 71.6% of benign lesions [excluding non-diagnostic samples (27.4%), sensitivity was 96.6% and specificity was 100%]. Tru-cut needle biopsy identified 82.9% of cancers and 61.7% of benign lesions [excluding non-diagnostic samples (33.3%), sensitivity was 96.7% and specificity was 100%]. There were no false positive errors with either aspiration cytology or needle biopsy. Statistical comparison showed that there was no significant difference between aspiration cytology and needle biopsy. The combined result of both biopsies was superior to clinical examination when non-diagnostic samples were excluded. With the routine use of both biopsy techniques, frozen section was avoided in 73% of all cancers and unnecessary operations were avoided in 33.5% of patients which included breast cysts, benign mammary dysplasia and inflammatory lesions.     

Needle-localized mammographic lesions. Results and evolving treatment strategy

From January 1981 to December 1987, 932 needle-localization breast biopsies were performed at our institution for mammographically detected abnormalities. We reviewed 531 needle-localization breast biopsy procedures performed during two periods (January 1981 to June 1984, n = 311; and January to August 1987, n = 220) to compare results and treatment patterns, and to determine the prevalence of the missed lesions. Mammographic abnormalities detected on routine screening accounted for a larger proportion of needle-localization breast biopsies in the later series (94 [30%] of 311 vs 94 [43%] of 220). However, the rate at which carcinoma was identified remained constant at 29% as did the percentage of cancers that were invasive (46% vs 51%). Overall, the rate of malignant diagnoses after needle-localization breast biopsy was lowest in asymptomatic women undergoing routine screening mammography (44 [24%] of 188) and significantly higher in women undergoing mammographic follow-up of the contralateral breast after treatment for breast cancer (28 [43%] of 65). There were seven missed lesions in 531 needle-localization breast biopsies, necessitating a second procedure in six and interval mammograms in one.     

Fine needle aspiration biopsy in the diagnosis and management of fibroadenoma of the breast

Cytological and histological biopsies were obtained on 75 breast lumps clinically diagnosed as fibroadenomas. Of these, 95 per cent of lesions were benign. In 51 (68 per cent) confirmed as fibroadenomas histologically, cytology was benign in 78 per cent, but inadequate for diagnosis in 16 per cent. The remaining 24 lesions included three breast cancers and one lymph node with Hodgkin's disease. In this group cytology was inadequate for diagnosis in 54 per cent, including one breast cancer. No lesion with benign cytology was subsequently shown to be malignant. The study supports the view that clinical diagnosis and cytology are accurate in the diagnosis of benign breast disease of this type. Breast cancer may rarely present with the clinical features of a fibroadenoma and too few lesions have been studied to assess fully the performance of cytological biopsy in detecting these small mobile lesions. A non-excisional policy should therefore include prolonged follow-up and repeat biopsy.     

Stereotactic fine needle biopsy of the breast.

The experience of the use of the TRC-Mammotest machine for stereotactic fine needle biopsy (SFNB) of the breast in Perth is presented. During the period 20 October 1988 to 10 January 1990, 404 SFNB were performed on 389 women with impalpable, mammographically detected lesions of the breast. Surgical biopsy was performed in 73 cases, of which 38 were malignant, giving a benign to malignant ratio in less than 1:1. The sensitivity for detecting cancer was 95%, with a positive predictive value of 100%. Using a combination of the mammographic and cytologic rating for the likelihood of cancer, all the cancers were detected and no cancers have developed in those considered mammographically and cytologically benign. The importance of a combined assessment of mammography and cytology in the management of patients with mammographically detected abnormalities is stressed.     

Dedicated Screening Mammography for Diagnosis of Small Breast Cancer

Breast cancer is the most common malignancy in women, and early diagnosis is a cornerstone of successful treatment. Mammography is the sole acceptable method for breast cancer screening, but its efficacy is still disputable. The aim of this study was to determine whether the influence of dedicated mammographic team skills could improve the diagnostic accuracy of screening mammography and detection of small breast cancers. From June 1992 to September 1996 a total of 17,393 screening mammograms and 335 mammographically guided needle-localization breast biopsies were performed. From August 1994, a dedicated mammographer commenced work in our hospital. Screening mammography and biopsy results were compared for the nondedicated period (NDP) and the dedicated period (DP). The biopsy rate decreased from 2.9% to 1.3% (p < 0.0001), and the positive biopsy rate increased from 26.3% to 48.2% (p < 0.0001) during the respective periods. The cancer detection rate not changed significantly (p = 0.27) through the whole study period, but the subgroup of small carcinomas (T0, T1a, T1b) increased significantly (p < 0.04), from 25 cases in the NDP to 40 cases in the DP. We concluded that dedicated mammography team skills can significantly improve the detection of small breast cancers and permit more effective diagnosis of breast cancer by reducing the number of breast biopsies ultimately found to be benign.     

STEREOTACTIC FINE NEEDLE BIOPSY OF THE BREAST

The experience of the use of the TRC-Mammotest machine for stereotactic fine needle biopsy (SFNB) of the breast in Perth is presented. During the period 20 October 1988 to 10 January 1990, 404 SFNB were performed on 389 women with impalpable, mammographically detected lesions of the breast. Surgical biopsy was performed in 73 cases, of which 38 were malignant, giving a benign to malignant ratio in < 1:1. The sensitivity for detecting cancer was 95%, with a positive predictive value of 100%. Using a combination of the mammographic and cytologic rating for the likelihood of cancer, all the cancers were detected and no cancers have developed in those considered mammographically and cytologically benign. The importance of a combined assessment of mammography and cytology in the management of patients with mammographically detected abnormalities is stressed.     

Loss of heterozygosity at 3p in benign lesions preceding invasive breast cancer

BACKGROUND: Loss of heterozygosity (LOH) at chromosome 3p is one of the most common genetic abnormalities identified in human cancers and has occasionally been noted in benign proliferative lesions predisposing to breast cancer. If the frequency of LOH at 3p in benign proliferative lesions correlates with the subsequent development of breast cancer, it may be possible to develop powerful tools for molecular risk assessment based on this technology. MATERIALS AND METHODS: Archival paraffin-embedded tissues from benign breast biopsies in five women who have developed breast cancer and three women who have not developed breast cancer were microdissected and allelotyped at 3p using six microsatellite markers. RESULTS: No LOH was detected in the biopsies from women who have not developed breast cancer. For women developing breast cancer, the proportion of informative loci showing LOH in the benign proliferative lesions was 0.47 as compared to 0.57 for the associated breast cancers. There was no LOH detected in epithelial DNA from a fibroadenoma. Of 15 informative loci, 4 (27%) showed LOH in both the benign proliferative lesion and the associated cancer; however, the actual parental allele lost was different in three of these four cases. CONCLUSIONS: These results suggest that there are specific patterns of genetic instability common to preneoplastic lesions and the breast cancers that subsequently develop even when the paired lesions are not clonally related. LOH analysis of benign breast epithelium may provide a tool for molecular risk assessment and a surrogate endpoint for breast cancer chemoprevention trials.     

Experience with fine-wire localization breast biopsies for nonpalpable breast lesions detected mammographically

There is evidence to suggest that the early diagnosis and treatment of breast cancer may be associated with a better prognosis. Technical advances such as mammography can detect nonpalpable breast lesions and changes associated with early carcinoma. With fine-wire localization under mammographic control, the surgeon can reliably remove nonpalpable lesions while sparing normal breast tissue. The authors describe the technique for fine-wire localization and removal of lesions and report their experience over 3 years with 262 women who underwent 269 biopsies for nonpalpable lesions. Four subgroups were identified: screened women who had no indication for mammography other than age, women who were referred for mammography by community physicians, a group referred to the Cancer Control Agency of British Columbia and a group referred to the agency for localization biopsy after mammography performed outside the Vancouver area had suggested a malignant lesion. The yield of cancers from biopsies was 10%, 38%, 43% and 26% respectively. The yield was significantly (p less than 0.05) lower for the screened group. Age over 60 years, previous breast cancer and mammographic technique were identified as possible predictors of a positive biopsy. The authors have found fine-wire localization biopsy a safe and reliable method of removing nonpalpable breast lesions.     

Pathology and treatment of impalpable breast lesions.

With the increasing use of mammography, more needle-localized breast biopsies (NLBB) are being done. The purpose of this study was to analyze the pathology of impalpable breast lesions and the impact of NLBB on treatment strategies. From 1985 to 1990, 1,605 NLBB were performed, of which 321 (20%) were malignant. Twenty-five percent of malignant biopsies demonstrated in situ disease only. The average size of all lesions detected was 16 mm, and, for invasive cancer, 12 mm. Eighteen percent of invasive cancers had metastasized to the axillary lymph nodes. Surgical management consisted of mastectomy in 74% of patients and breast conservation treatment (BCT) in 26%. No significant difference in surgical management for women 50 years of age or younger compared with those older than 50 years of age was noted. Although the use of BCT for eligible women is recommended by the National Institutes of Health, it is not widely practiced, possibly reflecting less physician acceptance of BCT. These observations suggest that the detection of smaller, impalpable breast cancers has had no impact on treatment strategies.     

Frequency and outcomes of benign breast biopsies in trans women: A nationwide cohort study

No literature is available on the benign versus malignant breast lesion ratio in trans women (male sex assigned at birth, female gender identity). As hormone treatment in trans women results in breast tissue histologically comparable with cis (non-trans) women, breast pathology may be expected. Previously, an increased breast cancer risk compared with cis men have been observed. We aimed to investigate the frequency and outcomes of breast biopsies in trans women. Therefore, we retrospectively examined the medical files of 2616 trans women. To gain data on breast lesions, we linked our cohort to a national pathology database. In this study we found that 126 people (5%) had one or more breast biopsies (n = 139). Of these, 21 trans women had a breast biopsy before the start of hormone treatment, and 53 after the start of hormone treatment. Breast biopsies were performed predominantly because of abnormalities during physical examination (37%, n = 51/139 biopsies), or because of capsular formation or contraction (28%, n = 16/57 biopsies) in trans women with breast implants. The most common breast lesions after the start of hormone treatment were fibroadenomas (n = 20), breast cancer (n = 6), fibrosis (n = 5), cysts (n = 4), and infections (n = 4). The benign versus malignant breast biopsy ratio was 88:12, which is comparable to the ratio in cis women (90:10). This study shows breast lesions in a limited number of trans women. Since the indications and outcomes of biopsies in trans women were similar to those in cis women, it seems reasonable to follow breast care guidelines as developed for cis women.     

Ultrasound-Guided Fine Needle Aspiration Biopsy Update 1998

Abstract: Breast ultrasound using a high-resolution, realtime, hand-held probe was performed on 19, 714 patients. Ultrasound-guided fine needle aspiration biopsy was done on 2,453 solid masses. We report on 2,075 of these lesions, 629 malignant and 1,446 benign, confirmed either by excisional biopsy or adequate follow-up. Of the cancers, 597 (95%) had either malignant or suspicious cytology with 1 false positive case and 32 false negative cytologic results. The diagnosis of cancer was delayed in four patients because of benign appearances on imaging and cytology. Surgery was performed promptly after the first imaging follow-up in each case. There was no delay in diagnosis in the remaining 11 patients because of the suspicious appearance of the masses on mammogram. Mammography missed 147 (23%) of the 629 cancers, 102 of which were clinically palpable. Forty-five cancers were both nonpalpable and not seen by mammogram (incidental cancers). A correct cytologic diagnosis, either fibroadenoma or nonspecific benign, was made in 1,339 of the 1,446 benign masses. The sensitivity of this technique in the diagnosis of solid breast lesions was 95%, the specificity was 93%, and the overall accuracy was 93%. We conclude that real-time, ultra sound-guided fine needle aspiration cytology is a valuable adjunct to the clinical, mammographic, and sonographic assessment of solid breast lesions.     

Accuracy of combined clinical-mammographic-cytologic diagnosis of dominant breast masses. A prospective study

Excisional biopsy is considered a mandatory part of the workup for patients with dominant breast masses. To evaluate the efficacy of a combined physical, mammographic, and fine-needle aspiration cytologic examination, 113 women were prospectively evaluated. Breast masses were listed as either benign or suspicious/malignant. All patients underwent a subsequent biopsy. Fifty-two (46%) of 113 patients had a malignant mass. The sensitivity and specificity of the individual tests were as follows: 96% and 66% for the physical examination; 94% and 73% for the mammographic examination; 90% and 93% for the fine-needle aspiration cytologic examination. For the 86 patients who underwent all three studies, the 25 patients with benign test results on all three examinations had a benign pathologic result. One (6%) of 18 patients with a single suspicious/malignant test result had cancer, 9 (64%) of 14 patients with two suspicious/malignant test results and 28 (97%) of 29 patients with three suspicious/malignant results also had breast cancer. We conclude that the combined triad of physical, mammographic, and fine-needle aspiration cytologic examinations is highly accurate in the diagnosis of breast masses, and patients in whom all three examination results are benign can be safely observed, obviating the need for an open biopsy.     

Results of MRI Screening for Breast Cancer in High-Risk Patients with LCIS and Atypical Hyperplasia

Background Magnetic resonance imaging (MRI) can detect breast cancer in high-risk patients, but is associated with a significant false-positive rate resulting in unnecessary breast biopsies. More data are needed to define the role of MRI screening for specific high-risk groups. We describe our experience with MRI screening in patients with atypical hyperplasia (AH) and lobular carcinoma in situ (LCIS). Methods We retrospectively reviewed data from our high-risk screening program prospective database for the period from April 1999 (when screening MRI was first performed at our institution) to July 2005. Patients with AH or LCIS demonstrated on previous surgical biopsy were identified. All patients underwent yearly mammography and twice yearly clinical breast examination. Additional screening MRI was performed at the discretion of the physician and patient. Results We identified 378 patients; 126 had AH and 252 had LCIS. Of these, 182 (48%) underwent one or more screening MRIs (mean, 2.6 MRIs; range, 1–8) during this period, whereas 196 (52%) did not. Those who had MRIs were younger (P < 0.001) with stronger family histories of breast cancer (P = 0.02). In MRI-screened patients, 55 biopsies were recommended in 46/182 (25%) patients, with 46/55 (84%) biopsies based on MRI findings alone. Cancer was detected in 6/46 (13%) MRI-generated biopsies. None of the six cancers detected on MRI were seen on recent mammogram. All six cancers were detected in five patients (one with bilateral breast cancer) with LCIS; none were detected by MRI in the AH group. Thus, cancer was detected in 5/135 (4%) of patients with LCIS undergoing MRI. The yield of MRI screening overall was cancer detection in 6/46 (13%) biopsies, 5/182 (3%) MRI-screened patients and 5/478 (1%) total MRIs done. In two additional MRI-screened patients, cancer was detected by a palpable mass in one, and on prophylactic surgery in the other and missed by all recent imaging studies. For 196 non-MRI-screened patients, 21 (11%) underwent 22 biopsies during the same period. Eight of 22 (36%) biopsies yielded cancer in seven patients. All MRI-detected cancers were stage 0–I, whereas all non-MRI cancers were stage I–II. Conclusion Patients with AH and LCIS selected to undergo MRI screening were younger with stronger family histories of breast cancer. MRI screening generated more biopsies for a large proportion of patients, and facilitated detection of cancer in only a small highly selected group of patients with LCIS.     

Fine-needle aspiration cytology in the diagnosis of primary breast cancer

To evaluate the role of fine-needle aspiration (FNA) cytology in the diagnosis of primary breast cancer, we reviewed our experience over a recent 5-year period at Harbor-UCLA Medical Center. A total of 590 aspirates with subsequent follow-up were documented. One hundred thirty-three primary cancers were histologically proved. Of the 133 cancers, 91 (68%) were diagnosed as malignant by aspiration cytologic examination; another 22 (17%) were reported as suspicious. Of the cancers, 8 (6%) had a benign cytologic diagnosis and 12 (9%) had unsatisfactory smears. No cytologic tests positive for malignancy were found to be benign on histologic examination. With an absolute sensitivity of 75% and a specificity of 100%, we conclude that FNA cytologic examination is highly accurate in the diagnosis of breast cancer. With no false-positive studies, the finding of a clearly malignant cytologic condition obviates the need for biopsy before mastectomy.